In-flight syncope as the first manifestation of severe cardiodepressive vaso-vagal syndrome, verified by tilt-table testing with delayed response

A 66-year-old woman with a history of in-flight sedentary syncope, with normal results of ambulatory diagnostics, was referred to Clinical Electrocardiology Department for invasive electrophysiology study.The study revealed normal parameters, with no arrhythmia induced; a head-up tilt-test was performed, resulting in type I response with mild bradycardia and transient symptoms. After being released from the tilt-table, and while in the sitting position, she experienced full syncope with 20 s episode of complete A-V block recorded. The diagnosis was verified to type IIB syncope and the patient was implanted with dual-chamber pacemaker. Syncope is one of the most frequent medical in-flight emergencies; however, it is predominantly linked with disturbed autonomic system response to hypobaric hypoxia. During tilt-table testing, the described delayed cardiodepressive response was very unusual, it can still lead to accurate diagnosis and effective treatment, with no recurrent symptoms.